How Are Privileges Determined for Forensic Mental Health Patients?

When is the right time for someone in the forensic mental health system to begin the process of transitioning back into the community?

What privileges does a person in the forensic mental health system have access to?

When can a person be discharged?

In general terms, these are very difficult questions to answer because every situation is as unique as a person’s DNA.

Before we dig deeper into those questions, perhaps some background information is required.

People enter the forensic mental health system because they are sick. They have come in contact with the law, but have been found by the courts to be Unfit to Stand Trial (Unfit) or Not Criminally Responsible (NCR).

Living with a mental illness does not, in and of itself, make someone Unfit or NCR.

A person is declared Unfit if a mental illness prevents that person from understanding the nature, object or consequences of the events that occur in court, or if that illness prevents the person from being able to communicate with and instruct his or her lawyer. Simply being diagnosed with a mental illness does not automatically make a person Unfit.

An NCR verdict is rendered if a person has committed an illegal act but, at the time, was suffering from a serious mental illness that prevented him or her from appreciating the nature or quality of the act or knowing that is was wrong.

Once a person is found NCR or Unfit, they leave the criminal justice system and enter the forensic mental health system, under the authority of the Ontario Review Board (ORB). From that point on, our job as a specialty mental health hospital is to treat their illness, provide them with the skills they need to effectively manage their mental health going forward, and to assist them in successfully transitioning back into the community when they are ready.

The ORB, which is a panel of psychiatrists, lawyers and community members, makes decisions regarding level of security, access to community privileges, and level of supervision required if a person is granted community access. These decisions are typically based on information provided by the person’s treatment team.

While our mandate is clear, every person and illness is different. There is no timeline, blueprint or instructional manual that works for everyone in quite the same way. The road to recovery requires intensive effort from the patient, family members and treatment team.

Now, let’s get back to those questions.

When is the right time for a patient to access privileges?

Privilege use is common throughout specialty mental health hospitals in Ontario, and prepares patients for an eventual safe transition to the community.

In order for a patient to successfully transition back into the community, it is imperative that he or she is gradually placed into community situations with success over time. At first, a patient may only be leaving our hospital’s grounds on escorted outings for community visits to places such as doctor’s offices. Depending on their mental state and behaviour on previous outings, their access to the community can gradually be increased. There are significant milestones which patients must achieve before greater privileges are granted. Each successful outing is considered a building block in their recovery and a step toward their eventual transition out of hospital.

What privileges does a patient have access to?

Starting with accompanied or escorted outings in the hospital and community, patients can earn the ability to walk the hospital grounds unaccompanied. This can then be expanded to permit unaccompanied access to the community for brief periods. Eventually, if all goes well, longer leaves of absences with family members that can span hours or even days can be granted.

The level of privileges granted is based on their response to treatment, such as medication and other therapies, and their ability to manage their illness and control their behaviour.

Privilege use is reviewed daily by the patient’s treatment team. If the person’s mental state becomes unstable, or their behaviour inappropriate, privileges can be revoked at any time by the treatment team.

Without these privileges it would be very difficult to assess whether a patient was ready for discharge. Without the ability for a slow, but consistent expansion of privileges, we could be putting the patient and the community at risk by sending a patient out in the community without the appropriate preparation, supervision and support.

When can a person be discharged?

Discharge occurs when a patient has consistently demonstrated an ability to manage their illness and has successfully begun to re-integrate into the community. In addition, we work with patients to secure the proper level of support and supervision (i.e. housing, health services, etc.) that they need to transition successfully to the community.

These questions are important, but it’s also important to understand that only a very small minority of those charged with crimes end up in the forensic mental health system, and only a small percentage of the patients in the system have committed serious offences such as murder.

Those treated in the forensic mental health system have low rates (7.5 - 10.4 per cent) of recidivism compared to the criminal justice system (41 - 44 per cent). Overall, our system has demonstrated its effectiveness in treating those suffering from severe mental illness, and in significantly reducing their risk of committing further offenses in the future.